Review Committee for Otolaryngology Case Log Coding ...

Review Committee for Otolaryngology
Case Log Coding Recommendations

The following Case Log Coding Recommendations have been provided in an attempt to establish some
degree of uniformity for all otolaryngology residents in terms of the logging of cases into the ACGME
Case Log System.

The Review Committee for Otolaryngology publicly thanks and credits the Harvard Otolaryngology
Residency Program for drafting the initially-proposed document which was utilized in the development
of these recommendations.

Please note that these recommendations additionally provide role definitions for Resident Surgeon,
Resident Assistant, and Resident Supervisor, and demarcate those procedural codes that define
Key Indicator Cases. Also included are instructions for the proper un-bundling of procedures for Case
Log recording (but not billing) purposes.

This document contains a linkable Table of Contents for electronic use, but is also designed to print in
booklet form (pages 2-5). It will be periodically updated by the Review Committee for Otolaryngology.
Notification of such updates will appear in the newsletter, RRC News for Otolaryngology.

Table of Contents

GENERAL/SINUS ..................................................................................................................................2
Emergency Department Procedures .................................................................................................. 2
Postoperative Complications.............................................................................................................. 2
Endoscopy: Airway and Foreign Body Cases .................................................................................... 2
Sinus Surgery .................................................................................................................................... 2
General/Pediatric: .............................................................................................................................. 2

PEDIATRIC AIRWAY AND NECK .........................................................................................................2
LARYNGOLOGY ...................................................................................................................................3
HEAD & NECK SURGERY ....................................................................................................................3

Endocrine Surgery ............................................................................................................................. 3
Neck Dissection ................................................................................................................................. 3
Salivary Gland Procedures ................................................................................................................ 3
Oral Cavity/ Oropharynx .................................................................................................................... 3
Laryngectomy .................................................................................................................................... 3
Anterior Craniofacial Resection.......................................................................................................... 4
Maxillectomy ...................................................................................................................................... 4
Excision of cutaneous facial lesion..................................................................................................... 4
H & N Ablative Procedures ................................................................................................................ 4
FACIAL PLASCTIC AND RECONSTRUCTIVE SURGERY...................................................................4
Free/Pedicled Flaps ........................................................................................................................... 4
Plastics / Trauma Cases: ................................................................................................................... 4
Microtia repair .................................................................................................................................... 5
OTOLOGY/NEUROTOLOGY .................................................................................................................5
Otology .............................................................................................................................................. 5
Ablative Otologic Procedures............................................................................................................. 5
Reconstructive otologic procedures: .................................................................................................. 5
Appendix: Key Indicator Cases by Type .............................................................................................6

*Asterisk by key indicator cases *Bronchoscopy with dilation: 31630
Rules for unbundling noted in blue *Bronchoscopy with tumor excision: 31640
Esophagoscopy, diagnostic: 43200
Role Definitions: Esophagoscopy with biopsy: 43202
Resident surgeon: performs ≥ 50% of the operation Esophageal dilation with bougie: 43450
with the attending physician or resident supervisor, 43453
over guidewire: 45456
including the key portions of the procedure retrograde: 43246
Resident assistant: performs < 50% of the operation, PEG/ G-tube placement: 42806
or ≥ 50% of the operation but not the key portions of Nasopharyngeal biopsy:
the procedure. Zenker’s: 43499
Resident supervisor: instructs/assists a more junior (endoscopic) 43130
(open) 43030
resident during a procedure in which the junior (open cricopharyngeal- myotomy)
resident performs ≥ 50% of the operation, including the
key portions of the procedure; the attending physician Sinus Surgery (log each side separately):

acts as an assistant or observer. Endo maxillary antrostomy: 31256

Endo frontal +/- tissue: 31276

GENERAL/SINUS Endo sphenoid: 31287

Endo sphenoid + tissue: 31288

Emergency Department Procedures: Endo biopsy or polyp or debridement: 31237

For any head and neck complex laceration repair: Endo concha bullosa: 31240

<1.0 cm: 13150 Endo DCR: 31239

1.1-2.5 cm: 13151 *Endo Ant ethmoid: 31254

2.6-7.5 cm: 13152 *Endo total ethmoid: 31255

Endo diag., maxillary b inf meatus: 31233

Flexible laryngoscopy: 31575 Endo nasal: 31231
Peritonsillar abscess drainage: 42700
Removal impacted cerumen: 69210 General/Pediatric:
Removal foreign body from ear: 69200
Removal of foreign body from nose 30300 Turbinate cautery, intramural: 30802
Epistaxis
-Anterior epistaxis control (simple): 30901 Turbinate cautery, superfic: 30801
-Anterior epistaxis control (complex): 30903
-Posterior packing placement: 30905 Turbinate excision: 30130
Septal hematoma: 30000
Auricle hematoma/abscess: 69000 Fracture inferior turbinate: 30930

Turbinate, submucous resection: 30140

Turbinate injection: 30200

Septoplasty: 30520

UPPP: 42145

T&A:

Postoperative Complications: >12 yrs: 42821
Neck exploration for hematoma:
Postoperative tonsil bleed requiring OR: 35800 <12 yrs: 42820
I&D superficial abscess: 42962
I&D deep space hematoma or abscess: 10060 Tonsil alone
21501
> 12yrs: 42826

<12 yrs: 42825

Adenoid alone:

Endoscopy: Airway and Foreign Body Cases: > 12yrs: 42831

DL, diagnostic: 31525 <12yrs: 42830

DL with biopsy: 31535 M&T:

Tracheoscopy or microlaryngoscopy with biopsy: M- 69420

31536 69421

*Bronchoscopy, diagnostic: 31622 T- 69433

*Bronchoscopy with BAL: 31624 69436

Awake fiberoptic intubation or Removal of ear tube under general anesthesia:

emergency intubation: 31500 69424

Cricoidotomy: 31605

Tracheotomy, planned: 31600 PEDIATRIC AIRWAY AND NECK

Tracheotomy, emergency: 31603 See also above codes for “Endoscopy: Airway and

DL with FB removal: 31530 Foreign Body”

Micro DL with FB removal: 31531 DL / tracheoscopy in pediatric patients: 31536

Removal FB pharynx: 42809 Supraglottoplasty: 31541

Esophagoscopy with FB removal: 43215 *Diagnostic DL of newborn: 31520

*Bronchoscopy with FB removal: 31635 *Tracheotomy = <2y: 31601

DL with dilation, initial: 31528 *Cricoid split: 31587

DL with dilation: subsequent: 31529

*LTR: 31582 Neck Dissection (log each side separately)
-Rib graft: 20910
31780 *MRND/SLND/SOHND: 38724
CTR / Trach R+R:
*Resection nasal dermoid: 30124 *Radical ND: 38720
30125
simple 42810 Submandibular gland excision: 42440
*complex 42815
*Branchial cleft anomaly not cyst: 60280 Deep cervical node biopsy:
*Branchial cleft cyst: 60281
*Thyroglossal duct cyst: 41599 (not a key indicator!) 38510
recurrent 30540
Tongue tie: If you get into IJ and repair it: 35201
Choanal atresia repair: 42720
Drainage of RP or PPS abscess 42725 SLN biopsy / excision: 38510
internal approach:
external approach: Excision soft tissue mass, neck: 21555

Excision tumor, deep neck: 21556

Drainage of RP or PPS abscess

via external approach: 42725

Resection parapharyngeal space tumor: 61605

Salivary Gland Procedures:

*Superficial parotid with FN dissection: 42415

LARYNGOLOGY: *Superficial parotid w/o FN dissection: 42410
Suspension microlaryngoscopy (SML)
with resection of polyp /mass: *Total parotid with FN dissection: 42420
SML resection nodule/submucosal mass
SML with PDL: 31541 *Total parotid with FN sacrifice: 42425
*SML with cordectomy: 31545
*SML with endoscopic hemi laryngectomy: 31541 -If you graft the FN: 64885
31370
antero-vertical: If you do a parotid/neck, log one of the above
latero-vertical: 31380
antero-latero-vertical: 31375 codes and log the neck procedure separately
VF injection / injection laryngoplasty: 31382
VF injection or injection laryngoplasty 31570 If mass goes into parapharyngeal space,
(with microsope/telescope):
Medialization thyroplasty: 31571 also log: 61590
Triple procedure: 31588
Adduction arytenopexy: If abdominal fat graft following parotid: 20926
Medialization thyroplasty: 31400
Cricothyroid subluxation: 31588 Submandibular gland excision: 42440
Office-based PDL: 31599
Office-based injection laryngoplasty: 31578 Selective neck dissection (levels 1A-1B): 38724
Laryngeal EMG: 31513
95865 Ranula: 42450

42408

Oral Cavity/ Oropharynx:

*Partial glossectomy w/o primary closure: 41120

*Hemiglossectomy w/o primary closure: 41130

Excision of oral tongue lesion without closure

41110

Excision tongue lesion with closure:

(anterior 2/3) 41112

(posterior 1/3) 41113

HEAD & NECK SURGERY Excision FOM lesion: 41116

*Resection of RMT or OP tumor 42844

Endocrine Surgery: *Excision mandible tumor: 21045

*Hemithyroidectomy: 60220 Log neck dissection separately if jointly

*Completion thyroidectomy: 60260 performed with oral cavity/OP resection

*Total thyroidectomy: 60240 Tooth extraction 41823

*Total thyroidectomy with pre-tracheal/

prelaryngeal dissection: 60252 Laryngectomy:

Thyroid case in which attending does most of Laryngectomy (without neck dissection to keep

the first lobe and you are surgeon on the other unbundled): 31360

side: (Log two different case IDs for each hemi Pharyngectomy:

thyroid - one as resident assistant and one as (when closed primarily) 42892

resident surgeon) (if requires flap for closure) 42894

*Parathyroid auto-transplantation: 60512 Unbundle for laryngopharyngectomy

*Parathyroidectomy: 60500 Supraglottic laryngectomy: 31367

-If you close the pharynx primarily

(pharyngoesophageal repair): 42953

-*If you take total thyroid: 60240

-*If you take hemithyroid: 60225 *Excision of FOM lesion: 41116
-*If you do MRND or SLND: 38724
-*If you do radical ND: 38720 *Partial glossectomy: 41120
-*If you do rotational SCM flap: 15732
-*If you assist in PIG *Hemiglossectomy: 41130
(pharyngeal interposition graft): 15758
-If you place a TEP: 31611 *Composite resection of tongue/FOM/mandible

(unbundle from neck): 41150

*Mandible excision alone for ORN: 21047

*Mandible excision alone for tumor: 21044

Auriculectomy: 69120

Anterior Craniofacial Resection:

Approach and tumor resection: 61580 FACIAL PLASCTIC AND RECONSTRUCTIVE
SURGERY
If you take the eye: 65110

*If you put in a flap, code as under free/pedicled flaps

category Free/Pedicled Flaps:
*RFFF (log assist if you help with inset):
Maxillectomy: 31225 *FFF (log assist if you help with inset): 15758
Maxillectomy 65110 *ALT (log assist if you help with inset): 20969
(including total, inferior, or medial): 42281 *Pec Flap: 15756
If you take the eye: *TPFF, or temporalis muscle flap, or 15734
Placement of pin-borne prosthesis: SCM rotational flap:
(all have same code) 15732

Excision of cutaneous facial lesion: *Cervico-facial rotational/advancement flap:
Malignant Lesion
<0.5 cm: if <10 cm2: 14060
0.6-1.0 cm:
1.1-2.0 cm: 11640 if 10-30 cm2: 14061
2.1-3.0 cm: 11641
3.1-4.0 cm: 11642 if > 30cm2: 14300
>4.0 cm: 11643
11644 *Paramedian forehead flap: 15731
11646
*Takedown of paramedian forehead flap
pedicle (2nd stage)
15630

Benign Lesion 11440 If you scrub in only to close: 15100
<0.5 cm: 11441 -Close the arm: 12035
0.6-1.0 cm: 11442
1.1-2.0 cm: 11443 skin graft: 14020
2.1-3.0 cm: 11444 arm wound: 14001
3.1-4.0 cm: 11446 -*Advancement closure of leg 12046
>4.0 cm: (fibula, ALT): 12055
-Close the chest (pec):
-Close the neck:
-Close the parotid:

Scalp Malignancy 11620 Plastics / Trauma Cases:
<0.5 cm: 11621
0.6-1.0 cm: 11622 Closed reduction of nasal fracture:
1.1-2.0 cm: 11623
2.1-3.0 cm: 11624 (“without stabilization”) 21315
3.1-4.0 cm: 11626
>4.0 cm: (if you placed a cast, finger cot or surgical) 21320

*Open reduction of nasal fracture:

(log this as closed rhinoplasty with bony work:)

30435

*Sentinel lymph node Box / Exec: 38510 *ZMC/midface fracture: 21360
If you inject ethylene blue dye, add 38792
(If done with Ophth, log orbital fx

as assist: 21390

H & N Ablative Procedures: and log canthotomy if done: 67715

Diagnostic DL: 31525 *Gilles approach for zygomatic

DL with biopsy: 31535 arch repair: 21356

Tracheotomy: 31600 *Mandible fracture:

If you explore neck for vessels (Log each aspect of case separately)

(suprahyoid) 38700 MMF: 21453

neck dissection, log SLND (see previous codes) ORIF mandible fx: 21462

*Open rhinoplasty: Implant BAHA: 69714

Septoplasty: 30520 (with STSG) 15120

*Rhinoplasty: 30410 Decompress VII: 69720

*Revision rhinoplasty: 30450 Endolymphatic sac decomps + shunts (two codes):

Nasal valve repair: 30465 Sac Decompression: 69806

Septal cartilage graft: 20912 *Mastoidectomy: 69502

Calvarial bone graft: 21210 Transcanal excise glomus tumor: 69550

Rhytidectomy: 15828 Eust Tube Catheter, transnasal: 69400

Platysmectomy (platysmal tightening): 15825

Facial plastics Botox inj. (not larynx) 96372 Ablative Otologic Procedures

Blepharoplasty: (log mastoids separately and unbundled from

(Log each eye and each site {upper or lower} reconstruction procedure codes!)

separately) *Simple mastoid: 69501

Upper blepharoplasty: 15822 *Complete mastoid (CWU): 69502

Lower blepharoplasty: 15821 *MR Mastoid (CWD stapes +/-malleus,

Repair ectropion: 67916 incus intact): 69505

Brow lift (any type): 67900 *Radical mastoid

Eyelid weight: 67912 (CWD all ossicles taken): 69511

Removal of eyelid weight: 67912 *Revise mastoid to complete: 69601

Tarsal strip: 67917 *Revise mastoid to Mod rad: 69602

*Revise mastoid to Rad: 69603

Gracilis free flap: Unbundle as appropriate *Mastoid obliteration: 69670
Myogenous free flap for paralyzed face:
Neurorrhaphy: 15842 Lateral TB resection: 69535
Fascia lata graft: 64886
20922 Auriculectomy: 69120

CPA tumor: 61520

STSG to face Reconstructive otologic procedures:
(eyelids, nose, mouth, lips, ears,neck):
Dermal graft (dermis alone)face or neck: 15120 Meatoplasty: 69310
15135
STSG: 15120

Exostoses/Canalplasty: 69140

Moh’s reconstruction (tissue rearrangement, *Tymp without OCR: 69631

advancement, rotational flaps): *Tymp with OCR:

*eyelids, nose, ear, lips (native tissue) 69632

<10cm2: 14060 (TORP or PORP) 69633

10-30cm2: 14061 *Tymp with mastoid and OCR: 69642

*forehead, cheek, chin, mouth, lips *** need to log multiple times to get key

<10cm2: 14040 indicators of tympanoplasty, mastoidectomy,

10-30cm2: 14041 and/or OCR

*takedown of melolabial flap pedicle 15630

Microtia repair 21230 Please see next page for appendix containing
1st stage with rib graft 14061 complete list of key indicator codes
*2nd stage lobule transposition 14061
*3rd stage elevation of auricle w/ STSG 15120
and for skin graft

OTOLOGY/NEUROTOLOGY

Otology 69660
*Stapes 69662
*Revision Stapes: 69440
ME Exploration (postauric or transcanal):
Cochlear Implant (two codes): 69930
69502
Insertion: 69717
*Mastoidectomy:
Replace BAHA:

Appendix: Key Indicator Cases by Type Bronchoscopy (rigid or flexible); with destruction of tumor or

relief of stenosis by any method other than excision (e.g.,

Congenital Neck Masses laser therapy, cryotherapy): 31641

Excision branchial cleft cyst or vestige, Bronchoscopy (rigid or flexible); with injection of contrast
confined to skin and subcutaneous tissues:
42810 material for segmental bronchography

(fiberscope only): 31656

Excision branchial cleft cyst, vestige, or fistula, Tracheobronchoscopy through established tracheostomy
extending beneath subcutaneous tissues
and/or into pharynx: 42815 incision: 31615

Excision dermoid cyst, nose; simple, skin, Bronchoscopy, rigid or flexible, with or without fluoroscopic
subcutaneous:
30124 guidance; diagnostic, with or without cell washing (separate

procedure): 31622

Excision dermoid cyst, nose; complex, under bone

or cartilage: 30125 Airway

Excision of vascular anomaly, axillary or cervical; Laryngoscopy direct, with or without tracheoscopy;

without deep neurovascular dissection: 38550 diagnostic, newborn: 31520

Excision of vascular anomaly, axillary or cervical; Laryngoscopy, flexible fiberoptic; with removal of foreign

with deep neurovascular dissection: 38555 body: 31577

Excision of thyroglossal duct cyst or sinus: 60280 Laryngoscopy, flexible fiberoptic; with removal 31578
of lesion:

Excision of thyroglossal duct cyst or sinus; recurrent: Arytenoidectomy or arytenoidopexy, 31400
60281 external approach:

Bronchoscopy Laryngoscopy direct, with or without tracheoscopy; with

Bronchoscopy, rigid or flexible, with or without fluoroscopic insertion of obturator: 31527
guidance; with brushing or protected brushings: 31623

Laryngoscopy direct, with or without tracheoscopy; with

Bronchoscopy, rigid or flexible, with or without fluoroscopic dilation, initial: 31528

guidance; with bronchial alveolar lavage: 31624

Laryngoscopy direct, with or without t racheoscopy; with

Bronchoscopy, rigid or flexible, with or without fluoroscopic dilation, subsequent: 31529

guidance; with bronchial or endobronchial biopsy(s), single

or multiple sites: 31625 Laryngoscopy, direct, operative, with
foreign body removal:
31530

Bronchoscopy, rigid or flexible, with or without fluoroscopic

guidance; with tracheal/bronchial dilation or closed Laryngoscopy, direct, operative, with foreign body removal;

reduction of fracture: 31630 with operating microscope or telescope: 31531

Bronchoscopy, rigid or flexible, with or without fluoroscopic Laryngoscopy, direct, operative, with operating microscope

guidance; with placement of tracheal stent(s) (includes or telescope, with submucosal removal of non-neoplastic

tracheal/bronchial dilation as required): 31631 lesion(s) of vocal cord; reconstruction with local tissue

flap(s): 31545

Bronchoscopy, rigid or flexible, with or without fluoroscopic

guidance; with removal of foreign body: 31635 Laryngoscopy, direct, operative, with operating microscope

or telescope, with submucosal removal of non-neoplastic

Bronchoscopy, rigid or flexible, with or without fluoroscopic lesion(s) of vocal cord; reconstruction with graft(s) (includes

guidance; with placement of bronchial stent(s) obtaining autograft): 31546

(includes tracheal/bronchial dilation as required),

initial bronchus: 31636 Laryngoscopy, direct, operative, with arytenoidectomy; with

operating microscope or telescope: 31561

Bronchoscopy, rigid or flexible, with or without fluoroscopic

guidance; with revision of tracheal or bronchial stent Laryngoscopy, direct, with injection into vocal cord(s),

inserted at previous session (includes tracheal/bronchial therapeutic: 31570

dilation as required): 31638

Bronchoscopy, rigid or flexible, with or without fluoroscopic Laryngoscopy, direct, with injection into vocal cord(s),
therapeutic; with operating microscope or telescope:
guidance; with excision of tumor: 31640
31571

Unlisted procedure, larynx: 31599 Glossectomy; complete or total, with or without
tracheostomy, without radical neck dissection:
Laryngoplasty; for laryngeal web, two stage, with keel
41140
insertion and removal: 31580

Laryngoplasty; for laryngeal stenosis, with graft or core Glossectomy; complete or total, with or without
tracheostomy, with unilateral radical neck dissection:
mold, including tracheotomy: 31582
41145

Laryngoplasty, cricoid split: 31587

Excision of lesion of tongue with closure; posterior

Laryngoplasty, not otherwise specified (e.g., for burns, one-third: 41113

reconstruction after partial laryngectomy): 31588

Ethmoid Excision of lesion of tongue with closure; with local

Nasal/sinus endoscopy, surgical; with ethmoidectomy, tongue flap: 41114

partial (anterior): 31254 Excision of malignant tumor of
mandible:
Nasal/sinus endoscopy, surgical; with ethmoidectomy, total 21044

(anterior and posterior): 31255 Excision of malignant tumor of mandible;
radical resection:
Ethmoidectomy; intranasal, anterior: 31200 21045

Ethmoidectomy; intranasal, total: 31201 Excision of benign tumor or cyst of mandible;

Ethmoidectomy; extranasal, total: 31205 requiring extra-oral osteotomy and partial

mandibulectomy (e.g., locally aggressive or

Thyroid destructive lesion(s)): 21047

Parathyroidectomy or exploration of parathyroid(s): Glossectomy; composite procedure with resection
60500
floor of mouth and mandibular resection, without

Parathyroidectomy or exploration of parathyroid(s); radical neck dissection: 41150

re-exploration: 60502 Glossectomy; composite procedure with resection
floor of mouth, with suprahyoid neck dissection:
Parathyroid autotransplantation: 60512
41153

Total thyroid lobectomy, unilateral; with or without

isthmusectomy: 60220 Glossectomy; composite procedure with resection

Total thyroid lobectomy, unilateral; with contralateral floor of mouth, mandibular resection, and radical neck
subtotal lobectomy, including isthmusectomy: 60225
dissection (Commando type): 41155

Thyroidectomy, total or complete: 60240 Neck Dissection 38700

Suprahyoid lymphadenectomy:

Thyroidectomy, total or subtotal for malignancy; Cervical lymphadenectomy
(modified radical neck dissection):
with limited neck dissection: 60252 38724

Thyroidectomy, total or subtotal for malignancy; Glossectomy; composite procedure with resection floor of

with radical neck dissection: 60254 mouth, with suprahyoid neck dissection: 41153

Thyroidectomy, removal of all remaining thyroid tissue Thyroidectomy, total or subtotal for malignancy; with limited
following previous removal of a portion of thyroid: 60260
neck dissection: 60252

Resection Oral Cavity 41120 Laryngectomy; total, with radical neck dissection: 31365

Glossectomy; less than 1/2 tongue:

Glossectomy; hemiglossectomy: 41130 Laryngectomy; subtotal supraglottic, with radical neck

dissection: 31368

Glossectomy; partial, with unilateral Pharyngolaryngectomy, with radical neck dissection;
radical neck dissection:
41135 without reconstruction: 31390

Pharyngolaryngectomy, with radical neck dissection; with mastoidectomy: 69530

reconstruction: 31395

Cervical lymphadenectomy (complete): 38720 Revision mastoidectomy; resulting in complete 69601
mastoidectomy:

Glossectomy; partial, with unilateral radical neck dissection: Revision mastoidectomy; resulting in modified radical
41135
mastoidectomy: 69602

Glossectomy; complete or total, with or without Revision mastoidectomy; resulting in radical 69603
tracheostomy, with unilateral radical neck dissection: mastoidectomy:

41145

Glossectomy; composite procedure with resection floor of Revision mastoidectomy; resulting in 69604
tympanoplasty:

mouth, mandibular resection, and radical neck dissection

(Commando type): 41155 Revision mastoidectomy; with apicectomy: 69605

Excision of parotid tumor or parotid gland; total, with Tympanoplasty with antrotomy or mastoidotomy (including

unilateral radical neck dissection: 42426 canalplasty, atticotomy, middle ear surgery, and/or

tympanic membrane repair); without ossicular chain

Thyroidectomy, total or subtotal for malignancy; with radical reconstruction: 69635

neck dissection: 60254

Tympanoplasty with antrotomy or mastoidotomy (including

Radical excision external auditory canal lesion; with neck canalplasty, atticotomy, middle ear surgery, and/or

dissection: 69155 tympanic membrane repair); with ossicular chain

reconstruction: 69636

Parotid

Excision of parotid tumor or parotid gland; lateral lobe, Tympanoplasty with antrotomy or mastoidotomy (including

without nerve dissection: 42410 canalplasty, atticotomy, middle ear surgery, and/or

tympanic membrane repair); with ossicular chain

Excision of parotid tumor or parotid gland; lateral lobe, with reconstruction and synthetic prosthesis (e.g., partial

dissection and preservation of facial nerve: 42415 ossicular replacement prosthesis (PORP), total ossicular

replacement prosthesis (TORP)): 69637

Excision of parotid tumor or parotid gland; total, with Tympanoplasty with mastoidectomy (including canalplasty,

dissection and preservation of facial nerve: 42420 middle ear surgery, tympanic membrane repair); without

Excision of parotid tumor or parotid gland; total, en bloc ossicular chain reconstruction: 69641

removal with sacrifice of facial nerve: 42425 Tympanoplasty with mastoidectomy (including canalplasty,

Excision of parotid tumor or parotid gland; total, with middle ear surgery, tympanic membrane repair); with

unilateral radical neck dissection: 42426 ossicular chain reconstruction: 69642

Mastoid Tympanoplasty with mastoidectomy (including canalplasty,

Craniectomy, bone flap craniotomy, transtemporal middle ear surgery, tympanic membrane repair); with intact

(mastoid) for excision of cerebellopontine angle tumor; or reconstructed wall, without ossicular chain

combined with middle/posterior fossa reconstruction: 69643

craniotomy/craniectomy: 61530 Tympanoplasty with mastoidectomy (including canalplasty,

Transcochlear approach to posterior cranial fossa, jugular middle ear surgery, tympanic membrane repair); with intact

foramen or midline skull base, including labyrinthectomy, or reconstructed canal wall, with ossicular chain

decompression, with or without mobilization of facial nerve reconstruction: 69644

and/or petrous carotid artery: 61596 Tympanoplasty with mastoidectomy (including canalplasty,
middle ear surgery, tympanic membrane repair); radical or
Transmastoid antrotomy (simple mastoidectomy): 69501 complete, without ossicular chain reconstruction: 69645

Mastoidectomy; complete: 69502 Tympanoplasty with mastoidectomy (including canalplasty,
Mastoidectomy; modified radical: 69505
Mastoidectomy; radical: 69511 middle ear surgery, tympanic membrane repair); radical or
Petrous apicectomy including radical
complete, with ossicular chain reconstruction: 69646

Mastoid obliteration (separate procedure): 69670

Total facial nerve decompression and/or repair

(may include graft): 69955 Tympanoplasty without mastoidectomy (including
canalplasty, atticotomy and/or middle ear surgery), initial or
Stapedectomy revision; without ossicular chain reconstruction: 69631

Tympanoplasty without mastoidectomy (including Tympanoplasty without mastoidectomy (including

canalplasty, atticotomy and/or middle ear surgery), initial or canalplasty, atticotomy and/or middle ear surgery), initial or

revision; with ossicular chain reconstruction revision; with ossicular chain reconstruction (e.g.,

(e .g, postfenestration): 69632 postfenestration): 69632

Tympanoplasty without mastoidectomy (including Tympanoplasty without mastoidectomy (including
canalplasty, atticotomy and/or middle ear surgery), initial or
canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic
prosthesis (e.g., partial ossicular replacement prosthesis
revision; with ossicular chain reconstruction and synthetic (PORP), total ossicular replacement prosthesis (TORP)):

prosthesis (e.g., partial ossicular replacement prosthesis 69633

(PORP), total ossicular replacement prosthesis

(TORP)): 69633

Tympanoplasty with antrotomy or mastoidotomy (including Tympanoplasty with antrotomy or mastoidotomy (including

canalplasty, atticotomy, middle ear surgery, and/or canalplasty, atticotomy, middle ear surgery, and/or

tympanic membrane repair); with ossicular chain tympanic membrane repair); without ossicular chain

reconstruction: 69636 reconstruction: 69635

Tympanoplasty with antrotomy or mastoidotomy (including Tympanoplasty with antrotomy or mastoidotomy (including

canalplasty, atticotomy, middle ear surgery, and/or canalplasty, atticotomy, middle ear surgery, and/or

tympanic membrane repair); with ossicular chain tympanic membrane repair); with ossicular chain

reconstruction and synthetic prosthesis (e .g, partial reconstruction: 69636

acicular replacement prosthesis (PORP), total ossicular

replacement prosthesis (TORP)): 69637 Tympanoplasty with antrotomy or mastoidotomy (including

Tympanoplasty with mastoidectomy (including canalplasty, canalplasty, atticotomy, middle ear surgery, and/or

middle ear surgery, tympanic membrane repair); with tympanic membrane repair); with ossicular chain

ossicular chain reconstruction: 69642 reconstruction and synthetic prosthesis (e. g,

partialossicular replacement prosthesis (PORP), total

Tympanoplasty with mastoidectomy (including canalplasty, ossicular replacement prosthesis (TORP)): 69637

middle ear surgery, tympanic membrane repair); with intact Tympanoplasty with mastoidectomy (including

or reconstructed canal wall, with ossicular chain canalplasty,middle ear surgery, tympanic membrane

reconstruction: 69644 repair); without ossicular chain reconstruction: 69641

Tympanoplasty with mastoidectomy (including canalplasty, Tympanoplasty with mastoidectomy (including canalplasty,
middle ear surgery, tympanic membrane repair); radical or
complete, with ossicular chain reconstruction: 69646 middle ear surgery, tympanic membrane repair); with

ossicular chain reconstruction: 69642

Stapes mobilization: 69650 Tympanoplasty with mastoidectomy (including canalplasty,

Stapedectomy or stapedotomy with reestablishment of middle ear surgery, tympanic membrane repair); with intact

ossicular continuity, with or without use of or reconstructed wall, without ossicular chain

foreign material: 69660 reconstruction: 69643

Stapedectomy or stapedotomy with reestablishment of Tympanoplasty with mastoidectomy (including canalplasty,

ossicular continuity, with or without use of foreign material; middle ear surgery, tympanic membrane repair); with intact

with footplate drill out: 69661 or reconstructed canal wall, with ossicular chain

reconstruction: 69644

Revision of stapedectomy or stapedotomy: 69662 Tympanoplasty with mastoidectomy (including canalplasty,
middle ear surgery, tympanic membrane repair); radical or
Tympanoplasty complete, without ossicular chain reconstruction: 69645

Revision mastoidectomy; resulting in tympanoplasty: Tympanoplasty with mastoidectomy (including canalplasty,
69604

Tympanic membrane repair, with or without site preparation middle ear surgery, tympanic membrane repair); radical or
of perforation for closure, with or without patch: 69610
complete, with ossicular chain reconstruction: 69646

Myringoplasty (surgery confined to drumhead and donor Flaps

area): 69620 Free muscle or myocutaneous flap with microvascular

anastomosis: 15756

flap; trunk: 15734

Free skin flap with microvascular anastomosis: 15757

Mandible/Maxilla

Free fascial flap with microvascular anastomosis: 15758 Closed treatment of mandibular or maxillary alveolar ridge

Free osteocutaneous flap with microvascular anastomosis; fracture (separate procedure): 21440

other than iliac crest, metatarsal, or great toe: 20969 Open treatment of mandibular or maxillary alveolar ridge

Free osteocutaneous flap with microvascular anastomosis; fracture (separate procedure): 21445

iliac crest: 20970 Closed treatment of mandibular fracture; without

Adjacent tissue transfer or rearrangement, scalp, arms manipulation: 21450

and/or legs; defect 10 sq cm or less: 14020 Closed treatment of mandibular fracture; with manipulation:
21451
Adjacent tissue transfer or rearrangement, scalp, arms

and/or legs; defect 10.1 sq cm to 30.0 sq cm: 14021 Percutaneous treatment of mandibular fracture, with

Adjacent tissue transfer or rearrangement, forehead, external fixation: 21452

cheeks, chin, mouth, neck, axillae, genitalia, hands and/or Closed treatment of mandibular fracture with interdental

feet; defect 10 sq cm or less: 14040 fixation: 21453

Adjacent tissue transfer or rearrangement, forehead, Open treatment of mandibular fracture with external

cheeks, chin, mouth, neck, axillae, genitalia, hands and/or fixation: 21454

feet; defect 10.1 sq cm to 30.0 sq cm: 14041

Adjacent tissue transfer or rearrangement, eyelids, nose, Open treatment of mandibular fracture; without interdental

ears and/or lips; defect 10 sq cm or less: 14060 fixation: 21461

Adjacent tissue transfer or rearrangement, eyelids, nose, Open treatment of mandibular fracture; with interdental
ears and/or lips; defect 10.1 sq cm to 30.0 sq cm: 14061
fixation: 21462

Adjacent tissue transfer or rearrangement, more than 30 sq Open treatment of mandibular condylar fracture: 21465

cm, unusual or complicated, any area: 14300 Open treatment of complicated mandibular fracture by
multiple surgical approaches including internal fixation,
Formation of direct or tubed pedicle, with or without interdental fixation, and/or wiring of dentures or splints:

transfer; scalp, arms, or legs: 15572 21470

Formation of direct or tubed pedicle, with or without Closed treatment of nasomaxillary complex fracture (LeFort

transfer; forehead, cheeks, chin, mouth, neck, axillae, II type), with interdental wire fixation or fixation of denture or

genitalia, hands or feet: 15574 splint: 21345

Formation of direct or tubed pedicle, with or without Open treatment of nasomaxillary complex fracture (LeFort II

transfer; eyelids, nose, ears, lips, or intraoral: 15576 type); with wiring and/or local fixation: 21346

Delay of flap or sectioning of flap (division and inset); at Open treatment of nasomaxillary complex fracture (LeFort II

scalp, arms, or legs: 15610 type); requiring multiple open approaches: 21347

Delay of flap or sectioning of flap (division and inset); at Open treatment of nasomaxillary complex fracture (LeFort II
forehead, cheeks, chin, neck, axillae, genitalia, hands, or type); with bone grafting (includes obtaining graft): 21348
feet: 15620

Delay of flap or sectioning of flap (division and inset); at Percutaneous treatment of fracture of malar area, including
zygomatic arch and malar tripod, with manipulation: 21355
eyelids, nose, ears, or lips: 15630

Forehead flap with preservation of vascular pedicle (e.g., Open treatment of depressed zygomatic arch fracture (e.g.,

axial pattern flap, paramedian forehead flap): 15731 Gillies approach): 21356

Muscle, myocutaneous, or fasciocutaneous flap; head and Open treatment of depressed malar fracture, including

neck (e.g., temporalis, masseter muscle, zygomatic arch and malar tripod: 21360

sternocleidomastoid, levator scapulae): 15732 Open treatment of complicated (e.g., comminuted or
involving cranial nerve foramina) fracture(s) of malar area,
Muscle, myocutaneous, or fasciocutaneous

including zygomatic arch and malar tripod; with internal techniques (e.g., head cap, halo device, and/or
intermaxillary fixation):
fixation and multiple surgical approaches: 21365 21435

Open treatment of complicated (e.g., comminuted or Open treatment of craniofacial separation (LeFort III type);

involving cranial nerve foramina) fracture(s) of malar area, complicated, multiple surgical approaches, internal fixation,

including zygomatic arch and malar tripod; with bone with bone grafting (includes obtaining graft): 21436

grafting (includes obtaining graft): 21366

Open treatment of orbital floor blowout fracture; transantral Rhinoplasty

approach (Caldwell-Luc type operation): 21385 Rhinoplasty, primary; lateral and alar cartilages and/or

elevation of nasal tip: 30400

Open treatment of orbital floor blowout fracture; periorbital Rhinoplasty, primary; complete, external parts including

approach: 21386 bony pyramid, lateral and alar cartilages, and/or elevation

Open treatment of orbital floor blowout fracture; combined of nasal tip: 30410

approach: 21387 Rhinoplasty, primary; including major
septal repair:
Open treatment of orbital floor blowout fracture; periorbital 30420
approach, with alloplastic or other implant: 21390
Rhinoplasty, secondary; minor revision (small amount of

Open treatment of orbital floor blowout fracture; periorbital nasal tip work): 30430
approach with bone graft (includes obtaining graft): 21395
Rhinoplasty, secondary; intermediate revision
Closed treatment of fracture of orbit, except blowout; (bony work with osteotomies): 30435

without manipulation: 21400 Rhinoplasty, secondary; major revision (nasal tip work and

Closed treatment of fracture of orbit, except blowout; with osteotomies): 30450

manipulation: 21401 Rhinoplasty for nasal deformity secondary to congenital

Open treatment of fracture of orbit, except blowout; without cleft lip and/or palate, including columellar lengthening; tip

implant: 21406 only: 30460

Open treatment of fracture of orbit, except blowout; with Rhinoplasty for nasal deformity secondary to congenital

implant: 21407 cleft lip and/or palate, including columellar lengthening; tip,

septum, osteotomies: 30462

Open treatment of fracture of orbit, except blowout; with

bone grafting (includes obtaining graft): 21408 ED_OTO_10_2011

Closed treatment of palatal or maxillary fracture (LeFort I

type), with interdental wire fixation or fixation of denture or

splint: 21421

Open treatment of palatal or maxillary fracture (LeFort I

type): 21422

Open treatment of palatal or maxillary fracture (LeFort I

type); complicated (comminuted or involving cranial nerve

foramina), multiple approaches: 21423

Closed treatment of craniofacial separation (LeFort III type)
using interdental wire fixation of denture or splint: 21431

Open treatment of craniofacial separation (LeFort III type);

with wiring and/or internal fixation: 21432

Open treatment of craniofacial separation (LeFort III type);

complicated (eg, comminuted or involving cranial nerve

foramina), multiple surgical approaches: 21433

Open treatment of craniofacial separation (LeFort III type);
complicated, utilizing internal and/or external fixation